lightning strikes twice: endovascular salvage of an early … pdfs/lig… · • axillary artery...
TRANSCRIPT
Kristine L. So, MD, Jo Cooke-Barber, MD, Kirstin Nelson, MD, Christopher
Walls, MD FACS, Sheppard Mondy, MD, FACSDivision of Vascular Surgery, Memorial University Medical Center, Savannah, GA
LIGHTNING STRIKES TWICE:
Endovascu lar sa lvage o f an ear ly
aort ic anastomot ic pseudoaneurysm
None applicable
DISCLOSURES
• Incidence 0.2 to 25%
• Likely underdiagnosed
• Incidence: femoral > iliac > aortic
• At diagnosis 8-40% are ruptured
• Mortality ranges from 61-67%
• Interval imaging at 3-5 years post-op
INTRODUCTION
• HPI: 61M transferred from an OSH with a 11.1cm AAA
with report of several weeks of epigastric, back, and left
flank pain
• PMH: MI s/p PCI 2016, HTN
• Meds: Plavix, Lisinopril, Lyrica
• Social: 30pk yr smoking hx
• Physical Exam:
▪ BP: 96/64 HR 68
▪ Epigastric tenderness, large pulsatile abdominal masses
▪ Palpable distal pulses
CASE PRESENTATION
CT abdomen/pelvis – PTD 0
• Bilateral iliac artery and suprarenal aorta
clamped
• Distal lateral wall blowout with laminated
thrombus – contained rupture
• 20mm tube graft
• Posterior wall secured with plegeted 3-0
prolene sutures
• End-to-end anastomosis to the aortic
bifurcation
PROCEDURE
• Extubated POD1
• Retained distal pulses
• Discharged home POD4
POST-OP
READMISSION
• Acute onset abdominal pain
• Hypotensive
• Emergent CTA
CTA OSH
OSH CT
• Femoral artery access for the aortic cuff
• Axillary artery access for visceral chimneys
• Patent visceral vessels
PROCEDURE OVERVIEW
• Axillary cutdown for axillary artery exposure
• Hemashield graft anastomosis for sheath access
• 3 x 7Fr sheaths in separate accesses
AXILLARY ACCESS
Bilateral renal arteries and SMA chimneys with Viabahn stents
VISCERAL STENTING
Overlapping aortic cuffs: 28 x 49 Endurant and 32 x 49 Endurant
AORTIC CONTROL
• High mortality rate
• Risk of pseudoaneurysm increases over time
• Inflammatory rind, difficult reoperative field
• Stent grafts also with complication risks: endoleaks,
thrombosis, migration, rupture, infections
• Serial post-operative imaging
• Endovascular approach is an excellent option for
pseudoaneurysm exclusion
DISCUSSION
LITERATURE CITED
Bez, L., Botelho, F., Maciel, J., et. al. Endovascular repair of abdominal aortic para-anastomotic pseudoaneurysm. J Vasc Bras. June 2013. 12 (2): 180-183.
Karkos, CD. Giagtzidis, IT, Kalogirou TE, et. al. Endovascular management of ruptured anastomotic pseudoaneurysm at the distal end of a prosthetic femoro-popliteal bypass: a “quick and easy fix.” Hippokratia 2015. 19 (2): 179-181.
Melissano, G., MD, Civilini, E., MD, Marrocco-Trischitta, M., MD, et. al. Resolution of an Anastomotic Aortic Pseudoaneurysm: 4 Years after Endovascular Treatment. Images in Cardiovascular Medicine. 2004. 31 (3): 330-332.
Trentadue, M., Puppini, G., Perandini, S., et. al. Endovascular Repair of an Unusually Complex Anastomotic Pseudoaneurysm of an Aorto-Basiliac Graft. Polish Journal of Radiology. 2017. 82: 244-247.